Is ready-to-eat-cereal consumption associated with nutrient adequacy and weight status in Hispanic- American children and adolescents?

Transcription

1 Louisiana State University LSU Digital Commons LSU Master's Theses Graduate School 2007 Is ready-to-eat-cereal consumption associated with nutrient adequacy and weight status in Hispanic- American children and adolescents? Solange Stella Pineda Vargas Louisiana State University and Agricultural and Mechanical College, Follow this and additional works at: Part of the Human Ecology Commons Recommended Citation Pineda Vargas, Solange Stella, "Is ready-to-eat-cereal consumption associated with nutrient adequacy and weight status in Hispanic- American children and adolescents?" (2007). LSU Master's Theses This Thesis is brought to you for free and open access by the Graduate School at LSU Digital Commons. It has been accepted for inclusion in LSU Master's Theses by an authorized graduate school editor of LSU Digital Commons. For more information, please contact

2 IS READY-TO-EAT-CEREAL CONSUMPTION ASSOCIATED WITH NUTRIENT ADEQUACY AND WEIGHT STATUS IN HISPANIC-AMERICAN CHILDREN AND ADOLESCENTS? A Thesis Submitted to the Graduate Faculty of the Louisiana State University and Agricultural and Mechanical College in partial fulfillment of the requirements for the degree of Master of Science In The School of Human Ecology By Solange Stella Pineda Vargas B.S., Universidad Industrial de Santander, Colombia, 1994 December 2007

3 DEDICATION This thesis is dedicated to my children, Andres Felipe, Laura Isabel and Carolina; and my husband Nicolas Gil who supported me through my graduate studies. I think of my children as my inspiration. ii

4 ACKNOWLEDGEMENTS I would like to express a sincere gratitude to my committee director Dr. Carol O Neil for her constant supervision, patience, and valuable suggestions throughout my graduate studies. My appreciation is also extended to my committee members Drs. Georgianna Tuuri and Michael Keenan for their comments, suggestions and spending their valuable time in reviewing my thesis. Dr. Michael Keenan for his support and his phrase Every thing happens for a reason and only my God knows why inspired me in hard times. Thanks to Drs. Annrose Guarino and Heli Roy for providing the economic support in my last semester. I am extremely thankful to my family, my husband Nicolas, my constant motivator, I love you; and my children Andres Felipe, Laura Isabel and Carolina for their love and patience, and for letting me take their time to study. Carito your phrase Work hard, study, read, believe in yourself, and do a good job is all that you need to make your family happy really helped me. Thanks to my parents, Manuel and Amparo for their everlasting affection and encouragement. Thanks to my siblings Sergio, Yolanda, Martha, and Yamile for their constant support. Thanks my mother-in-law Matilde Zapata for her moral support and taking care of my children during my hard time of my thesis work. I also would like to thank my friends: July, Melly, Jenny, Delia and Fabio, Jaime and Luz Edith, Alvaro and Tonya, Doña Luz and Dr. Narses, Chechy and Miguel, Carlos and Gloria whose support was fundamental in reaching my goals and for being my family in this country. Thanks God for blessing me during these years. My faith in God increased during my residence in this foreign land. iii

5 TABLE OF CONTENTS ACKNOWLEGEMENTS...iii LIST OF TABLES... vi LIST OF FIGURES...viii LIST OF ABBREVIATIONS AND ACRONYMS... ix ABSTRACT... xi CHAPTER 1 INTRODUCTION... 1 Statement of the Research Problem... 1 Rationale for the Study... 1 Objectives... 2 Hypotheses... 2 Assumptions... 3 Limitations... 3 Definitions... 4 CHAPTER 2 LITERATURE REVIEW Ready to Eat Cereal... 8 National Health and Nutrition Examination Survey Hispanics CHAPTER 3 SUBJECTS AND METHODS Research Design Participants Procedures Variables Statistical Analysis CHAPTER 4 RESULTS Consumption and Macronutrient Intake and Micronutrient Intake Nutrient Intake after Substracting Milk Mean Adequate Ratio and Micronutrient and Weigth Status CHAPTER 5 DISCUSSION Consumption and Macronutrient Intake and Micronutrient Intake Nutrient Intake after Substracting Milk Mean Adequate Ratio and Micronutrient iv

6 and Weight Status...45 Conclusions LITERATURE CITED VITA v

7 LIST OF TABLES 1. Mean daily macronutrient intake by breakfast consumption category: Hispanic- American children aged 1-5 years Mean daily macronutrient intake by breakfast consumption category: Hispanic- American children aged 6-12 years Mean daily macronutrient intake by breakfast consumption category: Hispanic- American children aged years Mean daily micronutrient intake by breakfast consumption category: Hispanic- American children aged 1-5 years Mean daily micronutrient intake by breakfast consumption category: Hispanic- American children aged 6-12 years Mean daily micronutrient intake by breakfast consumption category: Hispanic- American children aged years Mean daily macronutrient intake by breakfast consumption category without milk on cereal: Hispanic- American children aged 1-5 years Mean daily macronutrient intake by breakfast consumption category without milk on cereal: Hispanic- American children aged 6-12 years Mean daily macronutrient intake by breakfast consumption category without milk on cereal: Hispanic- American adolescents aged years Mean daily micronutrient intake by breakfast consumption category without milk on cereal: Hispanic- American children aged 1-5 years Mean daily micronutrient intake by breakfast consumption category without milk on cereal: Hispanic- American children aged 6-12 years Mean daily micronutrient intake by breakfast consumption category without milk on cereal: Hispanic- American adolescents aged years Mean adequacy ratio (MAR) as defined by the Recommended Dieatary Allowance (RDA) level of micronutrients by breakfast consumption category:hispanic-american boys and girls aged 1-5 years, 6-12 years, and years Mean adequacy ratio (MAR) as defined by the Recommended Dieatary Allowance (RDA) level of shortfall nutrients by breakfast consumption category:hispanic-american Boys and Girls aged 1-5 years, 6-12 years, and years vi

8 15. Mean waist circumference in cm by breakfast consumption category: Hispanic- American children aged 1-18 years Mean z-score of BMI-for-age mean percentile of BMI-for-age by breakfast consumption category: Hispanic-American Boys aged 2-18 years Mean z-score of BMI-for-age and mean percentile of BMI-for-age by breakfast consumption category: Hispanic-American Girls aged 2-18 years Percentage of children who were at risk of overweight or overweight by breakfast consumption category: Hispanic-American children aged 2-18 years vii

9 LIST OF FIGURES 1. consumption (%) by category in Hispanic children age 1-18 years 21 viii

10 LIST OF ABBREVIATIONS AND ACRONYMS AI: AT: BMI: CAPI: CDC: DFE: DGA: FNDDS: HA: Kcal: LSM: MAR: MEC: MUFA: NCHS: Adequate Intake Alpha-tocopherol Body Mass Index Computer- Assisted Personal Interview Centers for Disease Control and Prevention Dietary folate equivalent Dietary Guidelines for Americans Food and Nutrient Database for Dietary Studies Hispanic-American Kilocalories Least square mean Mean adequacy ratio Mobile examination centers Monounsaturated fat The National Center for Health Statistics NHANES: The National Health and Nutrition Examination Survey NWCR: PE: PUFA: RAE: RDA: RTEC: SAS: SE: National Weight Control Registry Physical examination Polyunsaturated fat Retinol activity equivalents Recommended Dietary Allowance Ready to eat cereal Statistical Analysis System Standard error ix

11 SFA: Saturated fatty acid SUDAAN: Survey Data Analysis USDA: The United States Department of Agriculture x

12 ABSTRACT consumption has been associated with an improved nutrient intake and diet quality in children and adolescents. Ready to eat cereal (RTEC) breakfast contributes to macro and micronutrient intake, because it is usually fortified with vitamins and minerals, and is low in fat and high in fiber content. The objective of this study was to examine the impact of RTEC consumption on nutrient intake and weight status in Hispanic-American (HA) children and adolescents using data from 1999 to 2002 The National Health and Nutrition Examination Survey (NHANES). Participants were categorized by breakfast skippers, RTEC breakfast, and other breakfast consumers. Hispanic-American children and adolescents consumed more other types of breakfast than an RTEC breakfast. Skipping breakfast was more common in HA adolescents than in children. Hispanic-American children and adolescents who consumed an RTEC breakfast had on average a lower intake of total fat and cholesterol than those who consumed other breakfast. Children between 1 to 5 years of age who consumed an RTEC breakfast had a higher mean energy intake from protein and a higher fiber intake than HA children who skipped breakfast. Hispanic-American in all age groups who consumed an RTEC breakfast had a better intake of vitamin B6, thiamin, riboflavin, niacin, folate, iron and zinc than those who consumed other breakfast and those who skipped breakfast. Children and adolescents met on average two-thirds of the Recommended Dietary Allowance (RDA) for Vitamin C and K, but did not average of the two-thirds of the RDA for vitamin E and fiber for any age regardless of the breakfast consumption pattern. Moreover, Adolescents who consumed an RTEC breakfast had a higher adequacy ratio (MAR) for shortfall nutrient intake than those who consumed others breakfast.. Children between 6 to 12 years of age who skipped breakfast had a significantly higher mean of xi

13 waist circumference than those who ate other breakfast; but this study found no significant association between the consumption of breakfast and skipped breakfast with the risk of overweight or being overweight in HA children and adolescent. xii

14 CHAPTER 1 INTRODUCTION Statement of the Research Problem Consumption of ready to eat cereal (RTEC) at breakfast, contributes positively to the nutritional quality of the diets of children and adults (1-3). Some studies have shown a possible role of RTEC breakfast consumption in reducing body weight (2, 4, 5). Nutrient intake in relation to the breakfast meal of Hispanics in the United States (US) has not been well studied. The purpose of this study was to determine if RTEC consumption at breakfast improved nutrient intake and weight status of Hispanic-American (HA) children and adolescents in the US using nationally representative data. Rationale for the Study The Hispanic population of the US includes individuals from Mexico, Puerto Rico, Cuba, and other countries from the Caribbean and Central and South America. In the US, this population has increased almost 100% from 22.4 million in 1990 to 42.7 million in Mexican-Americans are the largest Hispanic-origin group in the US (67% of Hispanics) (6). Data from the National Health and Nutrition Examination Survey (NHANES ) showed that the prevalence of overweight/obesity among Mexican Americans is increasing. Approximately 37% of Mexican American children 2 to 19 years of age are overweight or at risk of overweight (7, 8). There are many potential causes of overweight, but diets low in fiber and high in fat in children and adults, have been associated with overweight (9, 10). Obesity is a precursor of major health problems, including type 2 diabetes mellitus (9, 11) hyperlipidemia (12), and hypertension (11). 1

15 consumption has been associated with improved nutrient intake and diet quality in children and adolescents (1, 5, 13, 14). A breakfast of RTEC contributes to macro and micronutrient intake, because the cereal is usually fortified with vitamins and minerals, and is low in fat and high in fiber content (1-3, 15). Moreover, an RTEC breakfast is often accompanied by milk that increases intake of protein (16, 17), calcium (13, 18), and vitamins A and D (1, 2, 5, 17, 18). Some studies have shown a possible role of breakfast, especially an RTEC breakfast in reducing body weight (2, 4, 5, 16) and maintaining weight loss (19, 20). The purpose of this study was to examine the impact of RTEC consumption on nutrient intake and weight status in HA using data from NHANES 1999 to Objectives The objectives of the current study are to determine whether there is an: 1. association between skipping breakfast, or consuming an RTEC breakfast or other breakfast, with nutrient profiles in HA children and adolescents aged 1 to 18 years. 2. improved nutrient intake when milk is consumed with RTEC. 3. association between skipping breakfast, or consuming a RTEC breakfast or other breakfast, and measures of weight status in HA children and adolescents aged 2 to 18 years. Hypotheses The study has the following hypotheses: 1. HA children and adolescents who consume RTEC for breakfast will have a better nutrient profile than those who do not eat RTEC. 2. HA children and adolescents who consume RTEC will consume more protein, calcium, and vitamin A than those who do not consume it. 3. HA children and adolescents who consume RTEC for breakfast will be less likely to be at risk of or overweight than those who do not consume RTEC. 2

16 Assumptions The assumptions of this study were: 1. Participants or caregivers provided accurate responses to the NHANES surveys and questions about breakfast consumption and other questionnaire items. 2. The sample size is adequate to reflect accurately dietary intake in this population. Limitations Limitations of this study were: 1. Because of its cross sectional nature, the NHANES data set cannot be used to provide causal evidence between RTEC breakfast intake with nutrient adequacy and weight measures. 2. The 24-hour diet recalls have several inherent limitations: they may not reflect usual intake; they depend on memory; and subjects tend to under- or over-report. 3. Parents or caregivers who reported or assisted children with the recalls may not know all foods that children in daycare or school consumed the previous day. 4. RTECs were grouped together; and although the majority are fortified, those consumed may have varied considerably in energy, total carbohydrate, fiber, total and added sugar content, and exact fortification; whether RTEC were pre-sweetened was also not considered. 5. The category of RTEC also included other foods and these may contribute to the impact on weight parameters or nutrient intake. 6. Given the multi-colinearity in diet, there are a number of eating patterns that have been shown to be potentially associated with overweight. 7. The sample studied is primarily Mexican American, therefore the results may not be generalized to all HA populations in the US. 3

17 Definitions : is the first meal of the day consisting of any consumption of solid food, beverage, or both eaten in the morning, named by respondent as breakfast (English) or desayuno (Spanish) (21). Hispanic: The national survey NHANES defines persons of Hispanic-origin as those from Mexico, Puerto Rico, Cuba, and other countries from Central and South America (21). National Health and Nutrition Examination Survey (NHANES) is a national survey conduced by the National Center for Health statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). NHANES collects broad health information from personal interviews and medical examinations (21). Ready to eat cereal: Ready to eat cereal is a cereal food that is processed to the point that it can be eaten without additional preparation (e.g. boxed cereal) (22). In some studies RTEC is called breakfast cereal or fortified breakfast cereal (5, 13). The name RTEC is preferred since these cereals are not necessarily eaten only for breakfast (16, 18); however, for the purpose of this study only RTEC consumed at breakfast was considered. Shortfall Nutrients: are nutrients with an average intake lower than recommended intake for a group. The shortfall nutrients for children and adolescents are calcium; vitamin E; Potassium; calcium; magnesium; and fiber (23). 4

18 CHAPTER 2 REVIEW OF LITERATURE For this thesis, the definition of breakfast used by NHANES: the first meal of the day consisting of any consumption of solid food, beverage or both eaten in the morning, named by respondent as breakfast (English) or desayuno (Spanish) (21) was used. However, breakfast may have different meanings for different individuals. In one study, breakfast was defined as any food or beverage consumed between 5 to 10 AM (5). Another study defined breakfast as the first meal that involved solid food or beverage which occurred after waking up and before 10 AM on week days and before 11 AM on weekends (15). The different meanings of the word breakfast make studies of breakfast intake difficult to compare. The foods typically eaten at breakfast by the general population in the US are milk (46%), RTEC (28%), and breads/rolls (27%) (24). Eighty two percent of non-hispanic whites and Mexican Americans eat breakfast on any given day (25). There are differences in consumption patterns when people eat breakfast at home or away from home; one difference is that 77% of non-hispanic whites eat breakfast at home in comparison to 69% of Mexican Americans (24, 25). The type of food that non- Hispanics whites choose to eat at breakfast is different from what HA eat. For example, 20% of non-hispanic whites reported eating RTEC at breakfast in comparison to 12% of HA; and 14% of non-hispanic whites reported eating eggs in comparison to 18% of HA (26). Traditionally breakfast has been acknowledged as the most important meal of the day since it is associated with numerous benefits, including improved nutrient intake (1, 5, 14, 27, 28). A healthy breakfast meal or one that gives the required nutrient intake is undefined. 5

19 Although a National School Program breakfast must provide 25% of the Recommended Dietary Allowance (13) for energy, protein, calcium, iron, vitamin A and C (29). The other most cited benefits of breakfast consumption are its possible relationship to decreased the prevalence of overweight (2, 4, 13, 27), and improved academic performance in children and adolescents (13, 30). The latter is beyond the scope of this thesis and is not discussed further here. and Nutrient Intake The importance of breakfast in improving nutrient intake has been observed in several studies (1, 5, 14, 27, 28). One study in children aged 5 to 12 years found that breakfast provided approximately one-third of daily requirements for most nutrients (1). In a study in France, breakfast consumption was divided into three categories (based on the energy of RDA in France): low-energy (< 15% of the energy RDA), medium-energy (15-25% RDA), and highenergy (>25 % RDA) breakfast. The study showed that a high-energy breakfast contributed more than 50% of the RDA for riboflavin, 45% of the RDA for calcium and phosphorus, 33% of the RDA for magnesium, and 10-15% of the RDA for iron in children. This study also found that a high-energy breakfast was associated with a lower serum cholesterol intake than other breakfast categories; suggesting that a higher energy breakfast has a positive impact on nutrient intake of children and adolescents (27). Another study conducted in ninth-grade students found that the percentage of adolescents who consumed at least two-thirds of the daily RDA was higher for those who consumed breakfast than for those who skipped breakfast (14). A study in children 5 to 12 years of age found that those who consumed an RTEC breakfast more frequently had a higher intake of fiber; thiamin, niacin, riboflavin, iron, folate, and vitamins A, B12, and D, and a lower intake of fat and cholesterol than children who did not 6

20 (1). Similarly, the Growth and Health Study showed that girls between 9 to 19 years of age who consumed breakfast more frequently had a higher intake of calcium, iron, zinc, vitamin C, folate, and fiber than those who ate breakfast less frequently. However, the prevalence of those consuming decreased as they grew older (5). The Bogalusa Heart Study found that adolescent breakfast skippers had lower daily intakes of energy and protein per 1,000 Kilocalories (kcal) and did not meet two-thirds of the RDA for some vitamins and minerals (28). Eighty percent of Americans eat breakfast on any given day; however, breakfast consumption declined between 1965 and 1991; those most likely to skip breakfast are teens and young adults, particularly those adolescents who live in households with low incomes, headed by a single parent (31). Skipping breakfast could be one reason why children have decreased intake vitamins and minerals per 1,000 kcal as they grew older (32); and why many adolescents do not meet two-thirds of the RDA of vitamins A, C, K, E, and folate; calcium and magnesium (28, 32). and Weight Status Skipping breakfast has been reported to be inversely associated with body mass index (BMI) (2, 4, 5, 16). Children who consumed breakfast had a lower BMI for age than children who did not (5, 16). In the Growth and Health Study, girls between 9 to 19 years of age who consumed breakfast had a lower risk of overweight than those who did not eat breakfast (5). As girls grew older there was a lower prevalence of breakfast; and their BMI increased as they get older suggesting that as girl mature and skip breakfast an increase of BMI would be expected (5). Another study in children between 4 to 14 years of age showed an inverse relationship between breakfast intake and risk of overweight (16). The National Longitudinal Study of Adolescent Health, a prospective study of 9,919 adolescents (aged years of age in

21 and 18 to 27 years of age in 2002), associated skipping breakfast during the transition to adulthood with increased weight gain from adolescence to adulthood (33). The inverse relationship between BMI for age and breakfast cereal consumption may be due to the fact that most of the fortified cereals are low fat and because people who eat cereal may eat less energy dense snacks (4, 5, 16). Overweight (defined as a BMI for ages at or above the sex-specific 95 th percentile) among children has increased in the past decades in the US. Overweight in children increased by nearly 40% from 1976 to 2004 (7, 8). Diet quality is one element that has been inversely related with BMI (34). Diet quality and changes in eating patterns, such as increases in the number of meals away from home, large portion sizes, snacking and meal-skipping, may explain, in part, the increase of overweight (34, 35). However, some studies did not show an increase in eating frequency, snack, or evening eating, but did show breakfast consumption declined recently and this was associated with increased of overweight (19, 31). Eating breakfast may be related to maintaining weight loss (19, 20). A cross-sectional study, with 2,959 adult subjects in the National Weight Control Registry (NWCR), found that eating breakfast was a common characteristic in people who maintained weight loss (20). Ready to Eat Cereal Ready to eat cereal is a cereal grain product which has been processed to the point that it can be eaten without additional preparation (22). The first cereal package produced in the 1900s was corn flakes flavored with malt, sugar, and salt (36). After World War II when it observed that cereal was well accepted by large sector of the population, the decision was made to fortified cereal with B vitamins, including thiamin, riboflavin, niacin, and with iron to restore the micronutrient content of the whole grain lost during the manufacturing process (37). In the1950s and 1960s the popularity of RTEC led the development of cereals in many grain combinations, 8

22 shapes, flavors, and colors. In the 1980s, protein fortification was introduced to some cereals, to provide approximately 25% of the daily value of most nutrients per serving (36, 37). A breakfast meal containing RTEC has been shown to have a greater impact on nutrient intake than breakfast without RTEC (1, 3, 15). The principal nutritional benefit of RTEC results from fortification with vitamins and minerals; an RTEC breakfast has also been associated with decreased intake of fat and cholesterol, and increased intake of fiber (2, 5, 17, 27). These improved nutrient profiles have been associated with lower risk of disease. Decreased intake of total fat, saturated fatty acid (SFA) and cholesterol has been related to a decreased risk of coronary heart disease (38). Low dietary fiber intake has been associated with reduction of some types of cancer (9). A study of ninth-grade students showed that adolescents who consumed an RTEC breakfast had a lower intake of SFA and a higher intake of fiber per 1,000 kcal than those who consumed a fast food or another type of breakfast (17). Ready-to-eat-cereal consumption has been found to be related to desirable macro and micronutrient profiles. Ready-to-eat-cereal consumption also improved the recommended intake of fiber, carbohydrates, proteins and total fat (39). A study of Mediterranean children, adolescents, and young adults 2 to 24 years of age showed that intakes of thiamin, riboflavin, vitamin B6, vitamin D, folate, niacin, calcium, and iron increased with increasing consumption of RTEC; and subjects who consumed RTEC more frequently had lower total fat and higher fiber intakes than those with lower RTEC intakes. That study also showed increased consumption of dairy products with increased RTEC consumption (15). Ready-to-eat-cereal breakfast is often accompanied by milk which increases intake of protein (16, 17), calcium (13, 18), and vitamins A and D (1, 2, 5, 17, 18). Consumption of 9

23 RTEC with milk was associated with lower prevalence of dietary inadequacy of calcium in all age-sex categories (18). Another study of children 4 to 12 years of age found that children with a higher intake of RTEC had a higher intake of calcium than children with lower intake or RTEC (16). Ready-to-eat-cereal breakfasts have also been associated with a possible role in maintaining a healthful BMI. Studies in children showed a possible role of RTEC with maintaining healthy body weight (2, 4, 5, 16). In the Growth and Health Study three day food records were used to show that girls between 9 to 19 years of age who consumed RTEC had a lower mean BMI than girls who did not consume cereal. Girls who consumed cereal on only one or two days did not have a lower BMI when compared with those not consuming cereal; however, the analysis of this study may not have been appropriate because the BMI was not compared by age. Girls who consumed any cereal, regardless of how often they did so, had lower risk of overweight than those who did not eat cereal (5). Another study that followed 603 children between 4 to 12 years of age for 14 days found that children with higher intakes of cereal had lower risk of overweight than children with lower intakes (16). National Health and Nutrition Examination Survey History of NHANES The NHANES is a national cross-sectional survey guided by the NCHS that is part of the CDC and it is intended to evaluate the health and nutrition of the US Population (21). The information collected is strictly confidential and the privacy of the participants is protected by public laws (40). The NHANES program began in 1960 as the National Health Examination Survey, and it gathered information about known diseases and the distribution of a variety of physical, physiologic, and psychological measurements. In 1971, the nutrition component was 10

24 added and the name was changed to the NHANES. From 1971 to 1999 NHANES was conduced as a series of surveys that included a representative sample of the US population. In 1999, the program became continuous; this flexibility allows changes to the program that can to meet emerging needs (21, 40). Survey Participants This survey examines 5000 individuals every year from different regions of the country (21). Participants of this survey are from a broad range of age categories and different ethnic groups. In a study of HA, called Hispanic Health and Nutrition Examination Survey with 16,000 participants between 6 months to 74 years of age was conducted by NHANES (21). The NHANES 1999 to 2002 survey includes Hispanic populations from Mexico, Puerto Rico, Cuba and other countries from Central and South American (21); however, the majority of the participants were Mexican-Americans (67%). To produce valid information for HA, this group was over-sampled for the survey years used in this study. Each selected survey participant represents approximately 50,000 other US residents (40). NHANES Use and Contents The NHANES data are used in health sciences research and epidemiologic studies to assess nutritional status of the population and its association with health problems. The purpose is to document what people are eating and what their risk factors are for chronic disease. This survey collects information about the prevalence of chronic conditions in the population and disease risk factors and information on aspects of reproductive health, such as oral contraceptive use and breastfeeding practices (40). Health information from personal interviews and medical examinations is gathered by NHANES. The interview includes questions related to demographics, socioeconomic status, diet, 11

25 and health. The examination includes medical and dental examinations, anthropometric measurements including weight and height, and laboratory tests (21) including measurement of serum cholesterol and micronutrient levels. In the dietary interview, the information reported by the participant is recorded in a computer-assisted dietary interview software program that was developed by the survey. In this data set, a single 24-hour diet recall was used to determine intake of food and beverages; from this nutrient and total energy intake could be estimated (41, 42). Measurement aids and visuals including charts and drawings were used to quantify the foods and beverages reported by the participants. When the information provided by the participant was incomplete, interviewers performed data recovery by telephone. During the physical examination, the weight of the participant was measured by a digital scale that is connected to the injury surveillance information system; and the stature or recumbent length is measured with an electronic stadiometer that is also connected to the ISIS. Hispanics Hispanics are a heterogeneous ethnic group included in NHANES data collection. Hispanic is the term that describes people who are from or whose ancestors are from Mexico, Puerto Rico, Cuba, and other countries from the Caribbean and Central and South America. This population is the fastest growing minority group in the US and has increased by almost 100% since 1990 (22.4 million). At the end of 2005 Hispanics in the US numbered approximately 42.7 million (6). Mexican-Americans are the largest Hispanic-origin group in the US. Almost 67% of Hispanics, in NHANES are Mexican American and most studies are about this group (9, 11, 38). Nutrient Intake in Hispanic-American Few studies have been conducted on the diet of HA children; however, since children and adolescents usually eat food that their parents prepare, it is important to know the dietary patterns of HA adults. Nutrient intakes of HA are different depending on their country of birth, the 12

26 length of time they have lived in the US, and their acculturation level. Acculturation occurs when people of one cultural group adopt the behavior and beliefs of another group (43). Dietary intake varies in different generations of Hispanics in the US as a result of the effects of acculturation (44). Food choices of Hispanics can reflect positive or negative effects of acculturation (45). Acculturation has been associated with negative effects on diet quality in Mexican Americans (44). A study that analyzed dietary data on 2,853 Mexican-American women and men from the NHANES III found that Mexicans born in Mexico consumed more fiber; vitamins A, C, E, and B6, folate, calcium, potassium, and magnesium and less fat than did those born in the United States (46). Second generation Mexican American women had a lower average intake of protein; vitamins A and C; folate; and calcium than did the first generation of Mexican Americans women (44). The Massachusetts Hispanic Elders study found that more acculturated Hispanic elders consumed more SFA and less fiber than less acculturated Hispanics (47). These negative effects may be the result of poor food choices replacing traditional foods; for example, corn tortillas may be replaced by white bread. However, few studies have been conducted in Hispanics to demonstrate positive effects of acculturation on dietary quality and nutrient intake in this population. A study showed that the dietary quality and diversity of Puerto Rican elders was positively associated with acculturation (45). Obesity in Mexican Americans The prevalence of at risk of overweight or overweight among Mexican American male children increased from 21% in 1995 to 37% in Mexican American male children and adolescents have a greater prevalence of overweight (BMI 95 th percentile) than non- Hispanic white male children and adolescents (22% for Mexican American males and 17% for non-hispanic white males) (7). Obesity in children and adolescents can track into adulthood. 13

27 Overweight adolescents are likely to remain obese as adults (33, 48) with the associated increased risk of obesity-related health problems, such as hypertension, type 2 diabetes (9, 11), dyslipidemia, coronary artery disease (11), and joint problems (9). Mexican Americans aged 2-19 years have a 37% of prevalence of at risk of overweight (BMI 85 th percentile) or overweight in comparison with 25 % of non-hispanic whites of the same age (7). The difference in the prevalence of diabetes in Mexican Americans could be due to many factors such as genetic differences, but another important factor can be the higher incidence of overweight and obesity in Mexican Americans in comparison with non-hispanic whites. The Viva la familia study found evidence of a strong genetic contribution to the high prevalence of obesity and its risk factors for metabolic diseases in Hispanic children (49). The prevalence of obesity among Mexican Americans may be attributable to changes in dietary habits as a result of their acculturation overlaid onto a specific genetic background; both factors are important. Therefore, evaluation of the nutrient intake in Mexican Americans in the US is an important component of the overall nutritional risk factors for overweight/obesity in Hispanics The types of food eaten at breakfast by Hispanics are different from the type of food eaten by non-hispanic whites. A study that investigated the different food patterns of breakfast for adults aged in the US from 1994 to 1996 found that bread, eggs, and coffee were the most commonly consumed foods at breakfast by Hispanics. Twenty-five percent of Hispanics consumed some type of bread, 18% ate eggs, 15% drank coffee, and 12% consumed RTEC. That study also found that the variety of food consumed at breakfast provided different nutrient adjusting for caloric energy intake. For example, eggs were high in cholesterol, low in fiber, and low in iron and calcium, while RTEC were high in fiber, high in calcium density, and very low 14

28 in fat (26). A low fat and high fiber diet was associated with adequate nutrient intake of several vitamins and micro minerals in 15 years old adolescents (50). 15

29 CHAPTER 3 SUBJECTS AND METHODS Research Design This is a correlation study that used data from the NHANES survey to examine the impact of RTEC consumption at breakfast on nutrient intake and weight status in HA children and adolescents in the US. The survey was a stratified, multistage design since the data sets from and 2001 to 2002 were combined. Each participant represented approximately 50,000 non-institutionalized civilian Americans (40). Participants Participants were HA 1 to 18 years of age (n= 3,236) who participated in NHANES during For the 24 hour recalls, caregivers, usually parents, provided information for children 6 years of age or younger; children 12 years of age or younger were assisted by and adult; and children older than 12 provided their own information (51). Pregnant and lactating adolescents were excluded from this study. Participants were classified for gender and age (1 to 5 years, 6 to 12 years, 13 to 18 years) (52). Children were also categorized into one of three breakfast consumption groups: breakfast skippers (those who did not eat breakfast or brunch), RTEC breakfast consumers (regardless of what else was consumed at the breakfast/brunch meal), and other breakfast consumers (no RTEC was consumed at the breakfast/brunch meal). Due to the nature of the analysis (secondary data analysis), and the lack of personal identifiers, this study was exempted by the Institutional Review Board of the Louisiana State University AgCenter. Procedures The NHANES survey used standardized questionnaires and physical examinations to collect data at the mobile examination centers (MEC) (51). Interviews were conducted in 16

30 English, Spanish, or both by trained interviewers. Dietary intake information was collected using a single 24-hour food recall. During the MEC examination, participants completed additional questionnaires, including a dietary questionnaire. Computer-Assisted Personal Interview (CAPI) was also used to collect data (40, 52). The dietary interview room at MEC contains a standard set of measuring guides to help the respondents to estimate portion sizes of the food items consumed (53). The physical examination (PE) occurred within 1 to 2 weeks of the interviews. Physical examinations were performed in a MEC that was designed and equipped to survey participants. In the PE, waist circumference, height and weight were measured using standardized protocols and calibrated equipment. Waist circumference was measured at the narrowest part of the torso between the lowest rib margin and the iliac crest at the end of a gentle expiration. Measurements were taken to the nearest centimeter (cm) using a flexible tape (54). Body mass index was calculated from these heights and weight (21). Body mass index was calculated as weight in kilograms divided by height in meters squared and was rounded to the nearest tenth. In children and adolescents between 2 to 18 years, overweight and at risk of overweight were defined based on the sex-specific BMI for age growth charts (BMI-for- age z scores) from the CDC (21). The risk of overweight for children was defined as a BMI for age at or above the sex-specific 85th percentile but less than the 95 th percentile. Overweight was defined as a BMI for ages at or above the sex-specific 95 th percentile (21, 40). Variables Twenty-four hour diet recalls were used to estimate daily intake of total energy, fat, SFA, monounsaturated fat (MUFA), polyunsaturated fat (PUFA), total carbohydrates, added sugar, protein, and micronutrients vitamins A, E, C, K, B1, B2, B6, B12; niacin; folate; calcium; phosphorus; magnesium; iron; zinc; sodium; and potassium. The USDA Food and Nutrient 17

31 Database for Dietary Studies (FNDDS), version 1 (USDA database for dietary studies) was used in NHANES, , while the USDA Survey Nutrient Database was used to process the dietary interview data in NHANES, (55, 56). In the original release of NHANES, , data on vitamin A intake were only available in µg retinol equivalents, vitamin E intake data were only available in mg alpha-tocopherol equivalents, only total folate (µg) intake data, and no vitamin K (mg) or sugars (g) intake data were available as well. Currently, Dietary Reference Intakes for vitamin A, vitamin E, and folate are expressed as µg retinol activity equivalents (µg RAE), mg alpha-tocopherol (mg AT), and dietary folate equivalents (DFE), respectively (57-59). We used the special database released by USDA to determine vitamin A as mg RAE and vitamin E as mg AT (USDA Database information for A and E). The FNDDS was used to append the intakes of folate (DFE), vitamin K (µg), and total sugars (g) to the NHANES, , database. Added sugars food composition data were obtained from the Pyramid Servings Database for USDA Survey Food Codes version 2.0 (41). Added sugars were defined by the USDA as white sugar, brown sugar, raw sugar, corn syrup, corn syrup solids, high fructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, liquid fructose, honey, molasses, anhydrous dextrose, crystal dextrose, and dextrin that are eaten separately or used as ingredients in processed or prepared foods. To rule out the possibility that the nutrient contribution of eating RTEC for breakfast was attributable to milk added to the cereal, the daily nutrient intake of breakfast consumption groups was compared after deleting the nutrient intake from milk combined with RTEC consumed at breakfast. Daily nutrient intake from all foods except milk combined with RTEC consumed at breakfast was determined by summing the nutrient intake from all foods reported 18

32 in the 24-hour recall after excluding any fluid milk, other than soy milk, combined with RTEC eaten at breakfast. Dietary adequacy for micronutrients was examined as mean adequacy ratio (MAR), which was calculated by expressing micronutrient intake as a percentage of the RDA/Adequate Intake (AI), which was truncated to no more than 100%. The MAR for 5 shortfall nutrients (vitamin E and K, calcium, magnesium and fiber) in children age 1-18 years was also calculated by expressing nutrient intake as a percentage of the RDA/AI, truncated to no more than 100%. The percentage of energy from macronutrients was calculated using 24-hour dietary recall and estimates of the daily intake of total energy (60). The daily nutrient intake of breakfast consumption groups was also compared after subtracting the nutrient intake from milk that was combined with RTEC consumed at breakfast, in order to exclude the possibility that the nutrient contribution of eating RTEC at breakfast was attributable to the milk poured onto the cereal. The daily nutrient intake from all foods was calculated by summing the nutrient intake from all foods reported in the 24-hour recall after excluding any fluid milk. Statistical Analysis The Statistical Analysis System SAS (version 9, SAS Institute Inc, Carry, NC) and Survey Data Analysis for multistage sample design professional software package (SUDAAN) (version 9.0, Research Triangle Institute, Research Triangle Park, NC) were used for the analysis. SUDAAN takes into account the sampling weights and complex sample design for calculating variance estimates and was used to calculate standard errors of the mean (40). SUDAAN was also used to estimate sample-weighted least-square mean and standard errors for all nutrients examined. The Bonferroni correction was used to determine the statistical significances between means of breakfast skippers vs. RTEC breakfast consumers, breakfast 19

33 skippers vs. other breakfast consumers, and RTEC breakfast consumers vs. other breakfast consumers (52); there was an effective p-value of < Percentiles and z-scores of weight-for-age, and BMI-for-age were calculated using the SAS program for CDC Growth charts. For the analysis of BMI or BMI z-score the mean and standard errors were weighted and calculated by an estimation method in SUDAAN. Least squares means (LS means) defined as adjusted means were calculated after adjustment for age, gender, ethnic groups, and energy intake (40, 52). 20

34 CHAPTER 4 RESULTS Consumption The prevalence of breakfast consumption by HA aged 1 to 18 years is presented in Figure 1. There was a higher prevalence of skipping breakfast for those aged 13 to 18 years when compared with those aged 1 to 5 or 6 to 12 years. Five and a half percent of HA boys and 4.4% of HA girls between 1 to 5 years of ages; and 8.6% of HA boys and 9.3 % of HA girls between 6 to 12 years of age skipped breakfast in comparison with 26 % of boys and 30 % of girls between 13 to 18 years of ages Boys Girls Consumption (%) Skipper RTEC Other Years Figure 1: consumption (%) by category by Hispanic children aged 1-18 years. There was a lower prevalence of RTEC consumption breakfast in those aged 13 to 18 years than in those aged 1 to 5 or 6 to 12 years. Forty three percent of HA boys and 38% of HA 21

35 girls between 1 to 5 years of age and 35% of HA boys and 33 % of HA girls between 6 to 12 years of age consumed RTEC breakfast compared with 25.8 % of HA boys and 18 % of HA girls between 13 to 18 years of age. Of the HA children and adolescents eating breakfast, fewer consumed an RTEC breakfast than other breakfast. Thirty five percent of HA boys and 30% of HA girls consumed RTEC breakfast in comparison with 52% of HA boys and 55% of HA girls who consumed other breakfast. and Macronutrient Intake Table 1: Mean daily macronutrient intake by breakfast consumption category: Hispanic- American children aged 1-5 years. Macronutrient 1 % of energy 2 Skippers RTEC Other Protein (g) 50.3 ± ± 0.9 a 60.6 ± ± 0.3 b 59.3 ± ± 0.2 b Carbohydrate (g) 228 ± 19 ab 56.5 ± 3.9 ab 227 ± 4 a 55.7 ± 0.8 a 217 ± 3 b 53.3 ± 0.7 b Total Sugar (g) ± ± ± ± ± ± 0.5 Added Sugars (g) 93.3 ± ± ± ± ± ± 0.7 Total Fat (g) 59.3 ± 6.2 ab 32.6 ± 2.9 ab 55.2 ± 1.5 a 30.7 ± 0.7 a 59.9 ± 1.1 b 33.2 ± 0.8 b Saturated Fat (g) 24.1 ± ± ± ± ± ± 0.3 Monounsaturated Fat (g) 22.5± 2.5 ab 12.1 ± 1.1 ab 19.6 ± 0.6 a 10.8 ± 0.3 a 21.8 ± 0.5 b 12.0 ± 0.4 b Polyunsaturated Fat (g) 8.3± 0.8 a 4.6 ± 0.4 a 9.2 ± 0.3 a 5.0 ± 0.1 a 10.6 ± 0.2 b 6.0 ± 0.2 b Cholesterol (mg) 177 ± 32 a 176 ± 9 a 264 ± 10 b Total Dietary Fiber (g) 8.7 ± 0.8 a 11.7 ± 0.4 b 10.8 ± 0.4 b Source: NHANES, , sample with complete, reliable 24-hr recall dietary interview. a,b,c Means not sharing an alphabetic character differ significantly (p < 0.05) (Bonferroni corrected); breakfast skippers vs. RTEC breakfast consumers, breakfast skippers vs. other breakfast consumers, RTEC breakfast consumers vs. other breakfast consumers. 1 Least square mean and standard error (LSM + SE) nutrient intakes were adjusted for age, gender, and energy intake. 2 Least square mean and standard error (LSM + SE) percent energy from nutrients were adjusted for age and gender only. 22

36 Table 1 shows the mean daily macronutrient intake by breakfast consumption in HA children between 1 to 5 years. Those who consumed an RTEC breakfast had higher percent of energy from protein, and a higher intake of total dietary fiber than those who skipped breakfast. These children who consumed an RTEC breakfast had a higher intake of carbohydrates (grams[g]) and a higher percent carbohydrate intake than those who consumed other breakfast. Children who consumed an RTEC breakfast also had a lower energy intake and percent intake of total fat, MUFA and PUFA; and cholesterol than HA children who consumed other breakfast. Table 2: Mean daily macronutrient intake by breakfast consumption category: Hispanic- American children aged 6-12 years. Macronutrient 1 % of energy 2 Skippers RTEC Other Protein (g) 68.6 ± ± ± ± ± ± 0.3 Carbohydrate (g) 276 ± ± ± ± ± ± 0.9 Total Sugar (g) ± ± ± ± ± ± 1.2 Added Sugars (g) ± ± 1.0 a 96.0 ± ± 0.9 ab 90.7 ± ± 1.0 b Total Fat (g) 75.4 ± 2 ab 32.3 ± ± 1.3 a 31.4 ± ± 1.4 b 33.8 ± 0.7 Saturated Fat (g) 26.1 ± ± ± ± ± ± 0.3 Monounsaturated fat (g) 29.0 ± 0.8 a 12.4 ± 0.3 ab 26.4 ± 0.6 b 11.6 ± 0.2 a 29.3 ± 0.6 a 12.8 ± 0.3 b Polyunsaturated Fat (g) 14.6 ± 0.9 ab 6.2 ± 0.3 ab 12.4 ± 0.5 a 5.4 ± 0.2 a 14.5 ± 0.4 b 6.3 ± 0.2 b Cholesterol (mg) 227 ± 17 ab 205 ± 21 a 290 ± 18 b Total Dietary Fiber (g) 12.7 ± ± ± 0.4 Source: NHANES, , sample with complete, reliable 24-hr recall dietary interview. a,b,c Means not sharing an alphabetic character differ significantly (p < 0.05) (Bonferroni corrected); breakfast skippers vs. RTEC breakfast consumers, breakfast skippers vs. other breakfast consumers, RTEC breakfast consumers vs. other breakfast consumers. 1 Least square mean and standard error (LSM + SE) nutrient intakes were adjusted for age, gender, and energy intake. 2 Least square mean and standard error (LSM + SE) percent energy from nutrients were adjusted for age and gender only. 23

37 Table 2 shows the mean daily macronutrient intake by breakfast consumption category in HA children between 6 to 12 years. Hispanic children aged 6 to 12 years who consumed RTEC breakfast had a lower intake of total fat (g), MUFA (g and percent), PUFA (g), and cholesterol intake, than children who consumed other breakfast. HA children aged 6 to 12 years who skipped breakfast had a higher percent intake of energy from added sugars than HA children who consumed other breakfasts. Table 3: Mean daily macronutrient intake by breakfast consumption category: Hispanic- American adolescents aged years. Macronutrient 1 % of energy 2 Skippers Protein (g) Carbohydrate (g) Total Sugar (g) Added Sugars (g) Total Fat (g) Saturated Fat (g) Monounsaturated fat (g) Polyunsaturated Fat (g) 75.3 ± ± 0.4 RTEC 74.5 ± ± 0.3 Other 77.1 ± ± ± 7 a 311 ± 5 b 293 ± 3 a 53.0 ± 0.9 a 57.1 ± 0.8 b 53.8± 0.6 a ± ± ± ± ± ± ± ± ± ± ± ± ± 2 a 75.3 ± 1.9 b 80.7 ± 0.9 a 33.4 ± 0.7 a 30.3 ± 0.6 b 32.4 ± 0.4 a 29.1 ± ± ± ± ± ± ± 0.8 a 28.1 ± 0.8 b 30.5 ± 0.5 b 13.0 ± 0.3 a 11.3 ± 0.3 b 12.2 ± 0.2 a 15.8 ± ± ± ± 0.3 a 5.6 ± 0.2 b 6.5 ± 0.2 a Cholesterol (mg) 216 ± 10 a 212 ± 13 a 307 ± 9 b Total Dietary Fiber (g) 13.4 ± ± ± 0.4 Source: NHANES, , sample with complete, reliable 24-hr recall dietary interview. a,b,c Means not sharing an alphabetic character differ significantly (p < 0.05) (Bonferroni corrected) breakfast skippers vs. RTEC breakfast consumers, breakfast skippers vs. other breakfast consumers, RTEC breakfast consumers vs. other breakfast consumers. 1 Least square mean and standard error (LSM + SE) nutrient intakes were adjusted for age, gender, and energy intake. 2 Least square mean and standard error (LSM + SE) percent energy from nutrients were adjusted for age and gender only. 24